Intermittent Low-grade Fever Research Articles

Rescue splenic artery embolization in an adult patient of sickle cell disease presented with acute splenic sequestration crisis.

Splenic sequestration crisis is a potentially fatal complication of sickle cell disease, mainly seen in young children. Only a few case series describe the acute splenic sequestration crisis in adults and its management, which primarily consists of supportive care and, in some cases, splenectomy. Splenic artery embolization has seldom been described in sickle cell disease. This is probably the first case in which an adult with sickle cell disease presented with an acute splenic sequestration crisis was managed successfully through splenic artery embolization. This 22-year-old female, a known case of sickle cell disease, presented with severe pain in the abdomen and low-grade intermittent fever for two days, secondary to an acute splenic sequestration crisis. The diagnosis of acute splenic sequestration was made based on clinical and blood parameters, ultrasonography, and computed tomography. Even with adequate supportive care and blood transfusions, the patient's condition worsened with a rapid fall in the hemoglobin and total platelet count. Considering splenectomy to be a high-risk procedure for this patient, a decision of rescue splenic artery embolization was taken, which was successful. Splenic artery embolization may be considered a lifesaving procedure in patients with acute splenic sequestration, where the risk of splenectomy can be high. Adequate post-procedure supportive care is vital for preventing complications.

Renal Tuberculosis: A Case History that makes or Breaks the Case, Nothing is more Deceptive

This manuscript presents a compelling case of renal tuberculosis in a 15-year-old male, elucidating the intricate diagnostic hurdles and strategic management approaches encountered. The patient initially presented with nonspecific symptoms, including intermittent low-grade fever, weight loss, fatigue, and diffuse skin rashes, which were initially managed as suspected enteric fever. However, as the patient’s condition deteriorated, a comprehensive diagnostic exploration revealed renal tuberculosis. The report meticulously outlines the clinical presentation, diagnostic evaluation, and therapeutic trajectory, emphasizing the enigmatic nature of symptoms and advocating for a multidimensional diagnostic paradigm integrating clinical, radiological, microbiological, and histopathological assessments. Furthermore, this case report provides a comprehensive review of urogenital tuberculosis, discussing its epidemiological underpinnings, clinical manifestations, diagnostic methodologies, and therapeutic tenets. It underscores the paramount significance of early recognition and prompt initiation of treatment in forestalling complications and optimizing patient outcomes. This case report enriches the medical discourse by shedding light on the diagnostic intricacies and therapeutic imperatives pertinent to renal tuberculosis, especially in the younger demographic. We believe that the findings will contribute significantly to the understanding and management of this disease.

Infective Endocarditis - An uncommon presentation of disseminated melioidosis: a case report

Melioidosis is a potentially fatal bacterial infection involving multiple organ systems and is increasingly being reported in Sri Lanka in recent times. The clinical presentation of the disease varies from localized cutaneous infections to sepsis and death. Involvement of the heart in melioidosis is rare and only a few cases have been described so far in the world literature.Herein we report a case of infective endocarditis in a 53-year-old man with poorly controlled type 2 diabetes mellitus for 5 years duration, who presented with intermittent low-grade fever along with loss of appetite, and malaise for 5 months duration. Examination revealed tachycardia, generalized abdominal tenderness, and coarse crackles on the left lower lobe of the lung. No peripheral stigmata of infective endocarditis or murmur were present. Blood cultures were positive for Burkholderia pseudomallei. 2D echocardiography was performed to exclude infective endocarditis as a cause of prolonged fever which showed a healed vegetation on the mitral valve and contrast-enhanced computerized tomography revealed renal, liver, and lung abscesses with splenic infarctions. A diagnosis of disseminated melioidosis was made. He was successfully treated with three weeks of initial intensive therapy with intravenous meropenem and oral sulfamethoxazole-trimethoprim (TMP-SMX) followed by subsequent three-month eradication therapy with TMP-SMX. Disseminated melioidosis can manifest as infective endocarditis hence a high index of clinical suspicion along with 2D echocardiography and other relevant investigations are crucial for the diagnosis. Initiation of intensive therapy with meropenem in combination with TMP-SMX as an adjunct can be lifesaving.

Multiple Intracranial Tuberculomas In Immunocompetent Patient: An Uncommon Primary Manifestation Of Central Nervous System Tuberculosis (CNS TB)

Tuberculosis (TB) is a serious yet potentially-curable health issue among most developing countries including Pakistan. We report the case of an immunocompetent patient having multiple intracranial tuberculomas without evidence of meningitis which is an uncommon manifestation of CNS tuberculosis. A 50-year old man presented with 5 episodes of tonic-clonic generalized fits for 1 day, right sided body weakness for 2 weeks, generalized headaches and intermittent low-grade fever for 1 month. No contact or past history of tuberculosis was reported. On neurologic examination, there was hypertonia, exaggerated deep tendon reflexes and power of 3/5 in both right upper limb and right lower limb with a right plantar extensor response. CT scan (Brain) showed hyperdense areas in left frontal and temporal lobes with surrounding vasogenic edema. ESR was raised at 86 mm/hour. CSF analysis demonstratedRBC 0 cells/uL, WBC 783 cells/uL with 100% lymphocytes, Glucose 39 mg/dl andProtein 81 mg/dl with negative organism microscopy onAFB and Giemsa staining. However, CSF was positive for GeneXpert-PCR-MTB but drug resistance was not detected to rifampicin. Brain MRI with FLAIR demonstrated multiple disseminated, rim enhancing lesions with perilesional edema in bilateral cerebral hemispheres, thalami, left basal ganglia, medulla oblangata and cerebellum having no meningeal enhancement. Workup for immune-suppression was normal. A diagnosis of multiple intracranial tuberculomas was established and Anti-tubercular therapy was commenced. He was asymptomatic and taking ATT with good compliance having no adverse affects by 6-week follow up.

Basidiobolomycosis – An Unsightly Devastating Condition, Ironically Responsive to Inexpensive Medications: A Case Report with Review of Literature

Background: Basidiobolomycosis is an infection which results in an indolent, nonhealing, penetrating, unsightly destruction of subcutaneous tissues, rarely described in children. Clinical Description: A 6-year-old girl with no prior medical illness, presented with low-grade intermittent fever associated with an indurated swelling on the posterior aspect of her right leg, which gradually progressed over a period of 6 months into a deep, spreading, nonhealing ulcer, causing pain and restriction of movement. Management and Outcome: Routine blood investigations and swab cultures ruled out pyogenic infections and tuberculosis. She was negative for HIV. The wound was debrided, but there was poor response to antibiotics, fluconazole, and amphotericin B. Biopsy of debrided tissue revealed subcutaneous basidiobolomycosis. She was then treated with a combination of potassium iodide and cotrimoxazole. Over a 3-month period, the ulcer began granulating, and complete resolution was achieved through split-thickness skin grafting. Conclusion: Although uncommon, basidiobolomycosis may be considered in the evaluation of nonhealing penetrating ulcers, especially in immunocompetent children. Rather than expensive antifungals, potassium iodide and cotrimoxazole yield gratifying results in this condition.

Cerebritis as an initial presentation of systemic lupus erythematosus

Systemic lupus erythematosus (SLE), an autoimmune disease with multi-system manifestations, has several clinical presentations varying from mild muco-cutaneous involvement to severe multi-organ involvement. We report the case of an 18-year-old girl who presented generalized tonic clonic fits. She gave a history of generalized headaches, recurrent painless oral ulcers, photosensitivity, joint pains and low-grade intermittent fever. Magnetic resonance imaging (MRI) scan of the brain revealed T2WI/FLAIR hyperintense signals in bilateral frontal, parietal and occipital regions and magnetic resonance angiography of the brain demonstrated mild areas of luminal narrowing in M1 and M2 segments of middle cerebral arteries bilaterally, suggestive of lupus cerebritis. Anti-nuclear antibody (ANA) and Anti-DsDNA antibodies were positive. She was diagnosed as SLE and was prescribed corticosteroids, cyclophosphamide and hydroxychloroquine. This case highlights cerebritis as initial presentation of SLE.
 Abbreviations: ANA- Anti-nuclear antibody; CRP- C-reactive protein; FLAIR- Fluid attenuated inversion recovery; SLE- Systemic lupus erythematosus;
 Key words: ANA; Cerebritis; Headache; Systemic Lupus Erythematosus
 Citation: Ashfaq F, Butt NI, Rasheed MB, Ghoauri MSA, Anser A. Cerebritis as initial presentation of systemic lupus erythematosus. Anaesth. pain intensive care 2023;27(4):604−608; DOI: 10.35975/apic.v27i4.2214
 Received: May 23, 2023; Reviewed: May 28, 2023; Accepted: July 08, 2023

Subdural Tubercular Empyema in an Immunocompetent Patient: A Rare Primary Presentation of CNS Tuberculosis

Tuberculosis (TB) remains a potentially-curable serious health problem in most of the developing world including Pakistan. Subdural Tubercular Empyema is a very rare presentation of CNS tuberculosis. A 25-year-old gentleman presented with a 25-day history of low-grade intermittent fever and generalized headache. On examination, he had a temperature of 99.6oF with equally round and reactive to light pupils with normal extraocular muscle movements. However, there were signs of papilledema on fundoscopic examination. Signs' of neck rigidity (Kernig and Brudzinski) were negative. There was no focal neurological deficit. CSF analysis showed TLC 660 cells/uL with 100% lymphocytes, RBC 0 cells/uL, Protein 73 mg/dl, and Glucose 43 mg/dl with no organisms on Giemsa staining but positive AFB stain microscopy. GeneXpert-PCR for MTB was also positive on CSF with no drug resistance to rifampicin detected. His brain MRI scan showed left subdural empyema. Workup for the immunosuppressive condition was negative. He was diagnosed as having Subdural Tubercular Empyema and started on Anti-tubercular therapy. On follow-up at 4 weeks, he was asymptomatic and tolerating ATT without any adverse effects.

Multiple myeloma presenting as a lung plasmacytoma: A case report

Multiple myeloma (MM) is a clonal proliferation of malignant plasma cells mainly affecting the bone marrow. The most common sites of extramedullary dissemination reported in the literature are skin, liver, kidneys, and central nervous system. The presentation of MM with lung plasmacytoma is found to be very uncommon. We report a case of lung plasmacytoma associated with MM. A 65-years-old, non-smoker, female Ethiopian patient presented with 5 months history of dry cough, low grade intermittent fever, fatigue, anemia, hypercalcemia, renal insufficiency and osteolytic lesions in the skull. On a chest X-ray, she had right upper lung opacity with a well-defined margin medially. Fine-needle aspiration cytology from the lung mass lesion confirmed mononucleated and multinucleated plasmacytoid cells. The presentation of MM with lung plasmacytoma is a rare entity. As elderly patients with MM may first present with pneumonia-like presentation, MM or plasmacytoma should be considered as a differential diagnosis in an older patients presenting with thoracic lesion.

An Unusual Cause of Calcific Thoracic Metastases

An 18-year-old male presented with progressive breathlessness and cough of two months duration. He also complained of generalised body pains, low grade intermittent fever, anorexia and weight loss. He was started on empiric daily anti-tuberculosis treatment with rifampicin, isoniazid, pyrazianmide and ethambutol from elsewhere for right-sided pleural effusion one month ago. He presented to us as he did not experience improvement in his condition. There was no other significant medical history. Physical examination showed a 10cm x 8cm, non-tender hard bony mass with ill-defined margins over the upper third of left arm. There was no evidence of digital clubbing or peripheral lymphadenopathy. Respiratory system examination showed features of a right-sided pleural effusion.

Abstract 14984: Transient Constrictive Pericarditis: Pericardiectomy to the Rescue

Case Presentation: A 47 years old male presented with progressive dyspnea, bilateral leg and abdominal swelling, weight gain, and intermittent low-grade fever. He had a history of hypertension and chronic lymphocytic pericarditis complicated by an episode of constrictive pericarditis. Exam showed jugular venous pressure of 10 cmH2O, pericardial knock, and abdominal distention. Inflammatory markers were elevated (CRP 87.3 mg/dL, ESR 29 mm/hr). Echo showed abnormal increase in septal longitudinal motion and Doppler interrogation of the hepatic veins showed diastolic flow reversal at the end of expiration. Cardiac MRI showed pericardial thickening and circumferential delayed pericardial enhancement. Patient was diagnosed with transient constrictive pericarditis (TCP) and was treated with ibuprofen, colchicine, and prednisone and had improvement in his symptoms and inflammatory markers. However, he experienced another recurrence 6 months later and underwent pericardiectomy. Pathology showed organized fibrosis overlying the parietal fibrosa layer, mild neovascularization and perivascular chronic inflammation, confirming the diagnosis of TCP. After pericardiectomy, patient had significant symptomatic improvement and returned to his baseline activity level. Postoperative echo showed normalization of annulus longitudinal motion and cardiac MRI showed near resolution of pericardial delayed enhancement. He was successfully tapered off of his anti-inflammatory regimen. Discussion: TCP is a sub-type of constrictive pericarditis characterized by pathological findings of pericardial edema, acute or subacute inflammation, and fibrin deposition, as opposed to the fixed pericardial fibrosis and calcification seen in constrictive pericarditis. Constriction may resolve spontaneously, and anti-inflammatory therapy is the mainstay of treatment but in refractory cases like these, pericardiectomy comes to the rescue.

PROLONGED BLOOD HYPEREOSINOPHILIA AND EOSINOPHILIC ENTEROCOLITIS FROM PINWORM INFECTION ASSOCIATED WITH IGA AND IGE DEFICIENCY

<h3>Introduction</h3> Pinworm (<i>Enterobius vermicularis</i>) infection is generally considered a benign infection without systemic symptoms. However, severe infections can cause gastrointestinal inflammation, blood eosinophilia and systemic symptoms. What factors contribute to severe disease remains unclear. We present a case of pinworm infection causing prolonged blood hypereosinophilia and eosinophilic enterocolitis in a patient with severe combined IgA and IgE deficiency. <h3>Case Description</h3> A 16-year-old, non-atopic female presented at age 10 with intermittent low-grade fevers, abdominal pain and blood eosinophilia (AEC 3100 cells/mcL). Etiology was undetermined. As her abdominal pain continued, she was diagnosed with IBS; her blood hypereosinophilia persisted and remained unexplained. At age 15, she developed recurrent episodes of abdominal pain, non-bloody watery diarrhea and intermittent emesis. Evaluation revealed severe blood eosinophilia (AEC 6200 cells/mcL), elevated fecal calprotectin (95 mcg/gm) and gastrointestinal (esophagus, stomach, small and large intestine) eosinophilic inflammation. Direct endoscopic visualization, stool and serology testing for parasites were negative. Immunologic evaluation revealed mildly decreased IgG (621 mg/dL), undetectable IgE, low IgA (14.5 mg/dL) and normal IgM. Eosinophilia etiology remained undetermined; she was diagnosed with hypereosinophilic syndrome and treated with mepolizumab (anti–IL-5), which improved her blood eosinophilia but not her symptoms. Repeat EGD/colonoscopy (after 6 months) showed improved gastrointestinal eosinophilia but was notable for direct visualization of pinworms. Mepolizumab was discontinued. Albendazole completely resolved her symptoms; blood eosinophilia and IgG normalized, but IgA and IgE remained undetectable. <h3>Discussion</h3> Pinworms can cause persistent gastrointestinal disease and severe blood hypereosinophilia. We postulate that mucosal immunodeficiency secondary to IgA and IgE deficiency contributed to this presentation.

A 3-month-old child with miliary tuberculosis: a case report

Miliary tuberculosis (TB) is a severe form of disseminated TB that could be fatal without treatment. It remains a significant health problem in endemic countries such as Indonesia. A-3-month-old child was admitted to the hospital with chief complain of shortness of breath, cough, and intermittent low-grade fever. Significant clinical findings were lack of weight gain, previous contact with confirmed cases of TB, and severe malnutrition. Significant laboratory findings were anemia, elevated CRP, and hypoalbuminemia. Radiological findings were suggestive of miliary TB with bilateral diffuse reticulonodular lung lesion on chest CT-scan. Diagnosis of miliary TB is difficult because of nonspecific, atypical symptoms and varied clinical signs. It is needed multiple diagnostic approach, especially for children. Miliary TB remain to be a difficult case that require an early intervention despite difficulties in its diagnosis, to prevent morbidity and mortality of patient.

A CASE OF MICROSCOPIC POLYANGIITIS (MPA) FOLLOWING SARS-COV-2 INFECTION

A CASE OF MICROSCOPIC POLYANGIITIS (MPA) FOLLOWING SARS-COV-2 INFECTION

Isolated Bilateral Adrenal Histoplasmosis With Addisonian Crisis in an Immunocompetent Host

Bilateral adrenal histoplasmosis presenting as an adrenal crisis and being the only site of demonstrable disease in an immunocompetent adult is a rare presentation. The adrenal gland is frequently involved in disseminated histoplasmosis but commonly presents as unilateral mass; isolated bilateral involvement in an immunocompetent patient is rare. We describe a patient case of 38-year-old man presenting with epigastric pain, intermittent low-grade fever, nausea and vomiting, skin darkening, generalized weakness, and weight loss for 6 months. Investigations suggested primary adrenal insufficiency. On imaging, patient was found to have bilateral adrenal masses. The histopathological examination revealed Histoplasma species.

P486 Disseminated Cryptococcosis diagnosed on fine needle aspiration cytology

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PMObjectives (Case)A 48-year-old male with no prior comorbidities presented to our infectious disease clinic with intermittent low-grade fever and gradual progressive swelling in his left axilla for 3 months. On further probing, the patient also gives a history of weight loss of around 7 kg. The patient belonged to a northern state of the Indian subcontinent and owned a grocery shop, where he worked. There was no recent or remote travel history, no history of exposure to animals or birds, no high-risk behavior, and no past or known contact history of tuberculosis. Still, in an endemic country like India and in this given clinical scenario, we kept tubercular lymphadenitis as the first differential and investigated the case further.Methods (Investigation)A contrast-enhanced computed tomography (CECT) of the chest and abdomen was done, showing multiple enlarged mediastinal and axillary lymph nodes with bilateral adrenal mass (Fig. 1). To further evaluate the etiology, a fine needle aspiration of the left axillary swelling was done. A hematoxylin and eosin (H and E) stain of the same showed the presence of numerous organisms of varying sizes present both intracellularly and extracellularly along with chronic inflammatory cells (Fig. 2a). Based on this picture, differentials of Histoplasma, Cryptococcus, or Toxoplasma were kept. But considering the empty spaces (halos) which probably represent the capsule and variability in the size, a strong possibility of Cryptococcus was kept. Serum cryptococcal antigen (latex agglutination) was negative but eventually, the fungal culture of the aspirated sample grew cream-colored, shiny dome-shaped, mucoid colonies on Sabouraud Dextrose Agar suggestive of Cryptococcus (Fig. 2b). The same was confirmed on Bird Seed Agar and Matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry (MS). Gene Xpert of the aspirated sample was negative and serum cortisol with serum adrenocorticotropic hormone (ACTH) were under normal limits.Results (Diagnosis)A diagnosis of disseminated cryptococcosis was made based on the involvement of more than two non-contiguous sites (mediastinal with axillary lymph nodes and adrenal gland). The patient was initially started on liposomal Amphotericin B (5 mg/kg intravenous daily) with which he improved clinically. Same was continued for 2 weeks and later he was shifted to fluconazole 400 mg daily. As of now, the patient is on his 3rd month of fluconazole and doing well on follow-up.ConclusionCryptococcus (Cryptococcus neoformans and Cryptococcus gattii) is an encapsulated yeast causing invasive fungal infection, with vast majority occurring in immunocompromised host1. It has a global distribution, predominantly involving the central nervous system (CNS) and lung. Management of non-CNS and non-pulmonary cryptococcosis is tricky as looking for dissemination is key (as the initial choice of agent varies)2. Adrenal involvement in Cryptococcosis is uncommon (as seen in our case). Examination of FNAC samples for Cryptococcus is also challenging as other microbes can also closely mimic the same. Finally, in a tuberculosis endemic country like India, clinical symptoms of Cryptococcal lymphadenitis can closely resemble tubercular lymphadenitis, so empirical therapy may be risky.Figure 1 Axial CT Chest images showing multiple enlarged mediastinal lymph nodes (red arrow).Figure 2a Fine needle aspiration cytology (FNAC) from the left axillary swelling stained with hematoxylin and eosin showing numerous organisms of varying size present both intracellularly (black arrow) and extracellularly with surrounding halos in a background chronic inflammatory cells.Figure 2b Fine needle aspirate sample incubated at 37 0C on Sabouraud Dextrose Agar with gentamicin showing cream-colored, dome-shaped, shiny, mucoid colonies with smooth edge (characteristic of Cryptococcus).Sources:Iyer KR, Revie NM, Fu C, Robbins N, Cowen LE. Treatment strategies for cryptococcal infection: challenges, advances and future outlook. Nat Rev Microbiol. 2021 Jul;19(7):454–66.Clinical Practice Guidelines for the Management of Cryptococcal Disease: 2010 Update by the Infectious Diseases Society of America | Clinical Infectious Diseases | Oxford Academic [Internet]. [cited 2022 Jul 28]. Available from: https://academic.oup.com/cid/article/50/3/291/392360

Autoimmune Pancreatitis Presenting as Obstructive Jaundice – A Diagnostic Challenge

Autoimmune pancreatitis (AIP) is a rare form of pancreatitis which can mimic carcinoma head of the pancreas or distal cholangiocarcinoma, causing the diagnostic dilemma. A 64-year-old postmenopausal woman presented with jaundice, generalized itching, and intermittent low-grade fever for 2 weeks. On evaluation, she had a bulky pancreas on imaging and distal biliary stricture on magnetic resonance cholangiopancreatography. She was planned for Whipple's resection, but her serum immunoglobulin G4 (IgG4) was very high. She was started on oral high-dose steroids considering the possibility of AIP and had significant improvement after 2 weeks of treatment. AIP can mimic distal cholangiocarcinoma and can cause a diagnostic challenge in patients admitted with obstructive jaundice. The presence of high serum IgG4 level and treatment response to steroids help in making the diagnosis. This case reminds the readers to consider AIP in patients with obstructive jaundice who have imaging findings of distal cholangiocarcinoma to avoid unnecessary operations on patients without cancer.

Co-infection of Hepatitis A Virus with Salmonella Typhi

Waterborne diseases are very common in developing countries like Bangladesh due to intake of contaminated water from local water supply authority, along with inadequate sewage and water drainage systems. Multiple infections can occur with contaminated water. Viral hepatitis and typhoid fever are endemic in our country. Both are transmitted feco‐orally and are associated with poor sanitation, poor hygiene. Sometimes more than one type of infection along with coexisting febrile illness makes the diagnosis and management a challenging task. We report a case of 10 years young girl came to us with 10 days history of low grade intermittent fever, yellow discoloration of sclera and urine and right upper abdominal pain and final diagnosis was confirmed as co-infection of Hepatitis A and Salmonella typhi infection. KYAMC Journal. 2022;12(04): 250-251

Abstract 53: Acute thyrotoxic bulbar myopathy: An unusual presentation of hyperthyroidism

Background: Acute bulbar palsy manifested as thyroid storm is a rare presentation of hyperthyroidism.Aims and Objectives: We present a case of 22 year male presented with gradually progressive symmetrical weakness involving proximal muscles of both limbs since 1 year and new onset bulbar symptoms for last 15 days. It was associated with low grade intermittent fever, chronic diarrhea and significant weight loss. He was diagnosed as primary hyperthyroidism outside 6 months back but he discontinued medication since last 1 month. On presentation, he looked confused with staring look; skin was warm and moist with profuse sweating. Pulse rate was 140 beats per minute, regular; fine tremor was noted in both hands. Power was 3/5 in proximal muscles of both limbs with all reflexes diminished and flexor plantar.Results: On evaluation, FT4 was high 2.5 ng/dl, TSH was low 0.006 microIU/L, raised Anti TPO antibody (>1300 U/ml). Radio iodine uptake scan showed diffuse homogeneously increased tracer uptake in thyroid gland. CSF analysis, RNST, Anti cholinesterase antibody, NCS, EMG, and Neuroimaging were normal. He improved with antithyroid medication, beta blocker and steroid.Conclusions: Acute bulbar palsy is an uncommon but treatable complication of thyrotoxicosis that requires immediate intervention.

An Unusual Hepatic Origin of Fever and Weight Loss – A Case Report

Background: Sarcoidosis is a chronic multiorgan inflammatory condition with a wider variety of clinical presentations histologically characterised by non-caseating granulomas in the affected organ. Lung and lymph nodes are the most commonly involved organs, followed by liver, spleen, skin, eyes, heart and the nervous system. Although hepatic sarcoidosis is associated with pulmonary involvement, isolated hepatic disease is rare. Here we report a 37 year old gentleman, presenting with low grade intermittent fever, loss of appetite and 10kg weight loss in 9 months. Biochemical evaluation showed ALT 70 (20-47 U/L), ALP 402 (50-180 U/L), GGT 332 (19-50 U/L), bilirubin 0.9 mg/dl, Albumin 2.3 mg/dl, and INR 1.2. His abdominal imaging elsewhere showed multiple heterogenous areas in the liver diagnosed as cirrhosis and was referred to us for further management. A percutaneous liver biopsy showed multiple non caseating granuloma suggestive of sarcoidosis. His ACE level was elevated. He was started on corticosteroids following which there was dramatic improvement in clinical, biochemical and radiological parameters.

Abstract- Poster

BACKGROUNDSjogren's syndrome is the second most common autoimmune rheumatic disease after rheumatoid arthritis. Central nervous system (CNS) involvement in primary Sjogren's syndrome (CNS-SS) is a rare but significant complication and can manifest with focal or diffuse neurological deficits including psychiatric disorders.CASE REPORTWe discuss the case of a 19-year-old lady, who presented with twenty days history of hallucinatory behaviour, persecutory and referential delusions, inadequate self-care, decreased oral intake, and gradual onset mutism. Intermittent low-grade fever was present at onset. Examination revealed catatonic signs of mutism, negativism, immobility, and Gegenhalten. Preliminary investigations including CT brain did not indicate an organic aetiology. A diagnosis of acute psychosis with catatonic symptoms was made and she was initiated on Quetiapine and modified ECT. Though there was initial response, symptoms worsened and Quetiapine was declared failed. She was initiated on Olanzapine on which she developed significant extrapyramidal symptoms. Five weeks into her hospital stay, she developed bilateral upper and lower limb proximal muscle weakness. A detailed neurology evaluation was sought. Clinical findings and lab investigations were confirmatory for Sjogren's syndrome. She was diagnosed to have Primary Sjogren's syndrome (PSS) with CNS involvement and initiated on immunomodulators. Her symptoms improved gradually on regular follow up.CONCLUSIONClinicians should remember that pure psychiatric presentations of organic conditions are relatively rare. These should be looked for when there are atypical symptoms or when treatment response is unusual - treatment resistance or major side effects at relatively low doses. PSS should be in the list of differentials.